ABSTRACT

Context Adolescent drinking is a major public health concern. The federal government
does not restrict alcohol advertising to adolescents, but relies on the alcohol
industry for self-regulation.

Objectives To investigate recent alcohol advertising in magazines and to determine
whether advertising frequency is associated with adolescent readership.

Design, Setting, and Subjects All alcohol advertisements were counted that appeared from 1997-2001
in 35 of 48 major US magazines, which tracked their adolescent readership
(3 refused all alcohol advertisements; and advertisement counts were unavailable
for 10). Variation was assessed in the advertisement placement frequency for
each major category of alcohol (beer, wine and wine coolers, and distilled
liquor) by a magazine's adolescent readership (age 12-19 years), young adult
readership (age 20-24 years), and older adult readership (age ≥25 years);
readership demographics (sex, race, and income); year; frequency of publication;
and cost per advertisement.

Results Adolescent readership ranged from 1.0 to 7.1 million. The alcohol industry
placed 9148 advertisements at a cost of $696 million. Of the 9148 advertisements,
1201 (13%) were for beer, 443 (5%) for wine, and 7504 (82%) for liquor. After
adjustment for other magazine characteristics, the advertisement rate ratio
was 1.6 times more for beer (95% confidence interval [CI], 1.0-2.6; P = .05) and liquor (95% CI, 1.1-2.3; P = .01) for every additional million adolescent readers. Wine industry
advertising was not associated with adolescent readership.

Conclusions Magazine advertising by the beer and liquor industries is associated
with adolescent readership. Industry and federal policymakers should examine
ways to regulate advertising that reaches large numbers of adolescents.

Alcohol use among US adolescents has been identified as a key area of
focus for Healthy People 2010.1 Adolescent
drinking is associated with a host of negative consequences, including injuries,
suicides, driving under the influence of alcohol, driving fatalities, unsafe
or increased sexual activity, sexual assault, and acquaintance or date rape.2- 11 Episodic
heavy or binge drinking is particularly prevalent in this age group and is
associated with even more risk to both the individual and the community at
large.4 Yet in 2002, 20% of 8th graders admitted
to drinking an alcoholic beverage in the past 30 days, as well as 35% of 10th
graders, and 49% of 12th graders.12 Adolescent
drinkers have also been found to account for nearly 20% of total alcohol consumption,
spending an estimated $22.5 billion in 1999.13

Alcohol advertising has been shown to correlate at least modestly with
consumption.14- 17 Several
studies have found that children and adolescents who are exposed to greater
amounts of alcohol advertising are more likely to use or intend to use such
products.16,18- 22 The
possible link between advertising and consumption is of interest to several
professional organizations concerned with child welfare, including the American
College of Emergency Physicians23 and the American
Academy of Pediatrics.24- 26

The alcohol industry operates under no federal restrictions explicitly
aimed at advertising. Instead, voluntary self-regulation is the only form
of public policy control of alcohol advertising. The 3 major alcoholic beverage
trade associations (the Beer Institute, the Distilled Spirits Council of the
United States, and the Wine Institute) have created codes that pledge to advertise
and market to adults, and to specifically avoid advertising to adolescents.27- 29 The Federal Trade
Commission believes self-regulation is a "realistic, responsive, and responsible
approach to many of the issues raised by underage drinking."30 However,
several special reports to the Federal Trade Commission from the alcohol industry
corroborate evidence presented by researchers suggesting that a large fraction
of television and radio advertisements are shown to audiences that are primarily
adolescent.30

In 2000, the alcohol industry spent $1.42 billion on advertising through
television, radio, print, and outdoor advertisements, which is a 17% increase
from 1999.31- 33 The
beer industry spent $891 million; the distilled liquor industry, $365 million;
and the wine and wine cooler industry, $133 million. More than 77% of distilled
liquor advertising expenditures went to magazines. While the majority of beer
and wine advertising dollars were spent on television, magazine expenditures
accounted for 4% of beer and 28% of wine advertising expenditures, making
magazines the most important alcohol advertising outlet after television.
Recently, the Center on Alcohol Marketing and Youth reported that in a sample
of 98 magazines, nearly 30% of magazine alcohol advertising dollars were spent
in magazines with at least 25% adolescent readers.34 More
than half of the money was spent in magazines whose adolescent and young adult
audiences exceeded 15.8%, which is the proportion of the US population between
the ages of 12 and 20 years.

While the study reported that adolescents saw more beer and distilled
liquor advertisements than adults did, the study did not examine whether adolescent
exposure to these advertisements was beyond expected levels of incidental
exposure. In this study, we analyzed alcohol advertising in magazines from
1997 to 2001 to examine whether alcohol advertisement placement is associated
with adolescent readership.

METHODS

Data Sources

Magazine Readership. We obtained magazine readership
data from the Mediamark Research Inc database, an advertising industry group.35 Every 6 months, the advertising industry group conducts
face-to-face interviews supplemented with self-administered questionnaires
with more than 13 000 persons selected through stratified random sampling
of US households to track media and product usage. The group's data include
every major nationally distributed periodical published in the United States.
In 48 of the most widely read magazines in this data set, the group collects
data on both adolescent and adult readership.35 Readership
is measured not through purchases or subscriptions, but through actual self-reported
recent readership and can include shared magazines or magazines read in public
settings. We abstracted readership data for these 48 magazines from the advertising
industry group's fall 1999 report, the midpoint of our data collection period.
We divided total readership into 3 age categories tracked by the advertising
industry group: adolescents aged 12 to 19 years; young adults aged 20 to 24
years; and older adults aged 25 years or older. Although 21 years is the legal
age at which an individual can purchase alcohol in all 50 states, the advertising
industry group data we obtained did not distinguish between readers just older
and just younger than 21 years. Instead, we used the ages of 20 to 24 years
to represent those readers who were at or near the legal age.

Magazine Advertisement Placements and Expenditures. Advertisement placement and spending data were obtained from Competitive
Media Reporting, who compiles all advertisement placements and estimates expenditures
for all members of the Publishers Information Bureau.36 Advertisement
placement is an absolute count rather than a proportion of product advertisements
relative to a magazine's total advertisement content. We abstracted alcohol
advertisement and spending data for the 48 magazines, tracking each year from
1997 through 2001. Magazines that did not accept alcohol advertising as a
matter of policy were excluded because advertisers would not have considered
such magazines in their strategies. Of the 48 magazines, 3 (Seventeen, Teen, and YM) did not accept alcohol advertisements. Ten more were not completely
tracked by the media reporting group, leaving 35 magazines in the final data
set (Table 1). In general, magazines
that were not tracked by the media reporting group were either tabloid newspapers
(eg, National Enquirer, Star)
or special interest magazines (eg, Guns & Ammo, World Wrestling Federation Magazine). The final data set
did include 7 of the 10 most popular magazines among adolescents (Seventeen, Teen, and YM being excluded), and these 7 did accept alcohol advertisements (TV Guide, Sports Illustrated, National Geographic, People Weekly, Reader's Digest, Rolling Stone,
and Vibe).

Statistical Analysis

The media reporting group created 14 distinct categories of alcohol,
but we collapsed the categories into the 3 umbrella categories of beer, distilled
liquors, and wine and wine coolers. Within each umbrella category, a small
number of magazines did not have any advertisements across all 5 years. Responses
from telephone calls to the magazines suggested that most of these zeros were
due to magazine policies. These magazines were therefore dropped for individual
category analyses, leaving 27 magazines in the beer category, 31 in distilled
liquors, and 24 in wine and wine coolers. We counted the number of advertisements
placed by the alcohol industry in each umbrella category in each magazine
in each full year from 1997 through 2001.

We analyzed the data using regression analysis, in which the dependent
variable is the number of advertisements in each magazine in each year, and
the independent variables include magazine readership statistics and variables
such as the annual number of issues and the cost of placing an advertisement.
However, standard linear regression is inadequate for this type of data for
2 reasons. First, standard analysis assumes each observation to be independent
of every other observation. Observations are unlikely to be independent because
the number of advertisements placed in 1 magazine in 1 year probably correlates
strongly with the number of advertisements placed in the same magazine in
previous or subsequent years. We corrected for this lack of independence by
using generalized estimating equations, a common method of longitudinal data
analysis that accounts specifically for these correlations.37 Second,
standard regression analysis assumes that responses are at least approximately
normally distributed across observations and that the mean of responses is
a linear function of covariates. When the observations are counts that are
positive, they tend to have many small values and a few large values and are
unlikely to be normally distributed. In our analysis, we used Poisson regression
for the logarithm of the advertisement rate (ie, the mean number of advertisements
placed per magazine per year). Regression coefficients in this model are reported
as advertisement rate ratios (ARRs), which is the proportional difference
in advertisement rate for each unit difference in readership.

We performed analyses to confirm the above assumptions of nonindependence
and nonnormality. First, we confirmed that advertisement placement in a magazine
in a given year correlated strongly with advertisement placement in the same
magazine in every other year. Using generalized estimating equations, we were
able to incorporate this correlation pattern (the exchangeable correlation)
into our model assuming all correlations are approximately equal. After model
fitting, we also graphed the distribution of advertisement count residuals
across observations to confirm that our regression model for the log advertisement
rate was an accurate representation of the data. However, we found greater
variability in the number of advertisements than would be expected from the
Poisson model (overdispersion). To make our inferences more robust, we used
the sandwich estimator, which is an alternative method of determining SEs
and confidence intervals (CIs) that is commonly used with generalized estimating
equations. This method automatically accounts for the possibilities that the
data are overdispersed and that the correlations among the annual observations
on a given magazine are not exactly equal.

For each alcohol category, we regressed the log annual advertisement
rate on the number of readers of that magazine who were between the ages of
12 and 19 years. We examined the number of readers rather than the percentage
of readership because advertisers often calculate their ability to reach an
audience using absolute numbers.38 Bivariate
analyses were performed for each alcohol category, followed by multivariate
analyses to control for potential confounders.

Because the most obvious potential confounder was the number of adults
that could be reached through that magazine, we controlled for both the number
of readers aged 20 to 24 years and the number of readers aged 25 years or
older. We also controlled for the numbers of adult male readers; adult black
readers; adult readers with an annual household income of less than $30 000
or an annual household income of greater than $60 000; the frequency
of publication; and the average cost per advertisement. We estimated the average
cost per advertisement in each magazine in each alcohol category and in each
year and used the log average cost per advertisement as a covariate. Finally,
year was included as a set of 4 indicator covariates. STATA statistical software
was used (Version 7.0, STATA Corp, College Station, Tex); and P<.05 was the level of significance.

RESULTS

Univariate Description

From 1997 through 2001, the alcohol industry spent $696 million placing
9148 advertisements in the 35 magazines in the sample. Beer advertisements
accounted for 13% (1201) of the total, wine and wine coolers 5% (443), and
distilled liquor 82% (7504). Overall, annual placement of alcohol advertisements
in the magazines decreased by 29% between 1997 and 2001, with similar declines
in each category. However, annual expenditures for alcohol advertisements
in the magazines increased by 27% during the same period, and the average
cost per advertisement increased by 79% from $57 500 to $103 000.
The downward trend in advertisements and the upward trend in expenditures
were generally consistent across magazines and alcohol categories and mirror
trends for other industries during the same period, such as tobacco.39 Thus, these findings may reflect global rather than
industry-specific changes in magazine advertising.

The number of alcohol advertisements placed in each of the magazines
over the 5-year period ranged from 2 to 1842. The number of readers aged 12
to 19 years ranged from 1.0 million to 7.1 million (Table 1).

Bivariate Analyses

Using generalized estimating equations, we found that there were 1.6
times more beer advertisements in a magazine for each additional 1 million
readers aged 12 to 19 years (95% CI, 1.3-2.0; P<.001).
There were 1.3 times more distilled liquor advertisements in a magazine for
each additional 1 million readers aged 12 to 19 years, but this association
was not statistically significant (95% CI, 0.95-1.70; P = .11). There were neither more nor less wine and wine cooler advertisements
in a magazine for each additional 1 million readers aged 12 to 19 years (ARR,
1.00 [95% CI, 0.68-1.60]; P = .85).

Multivariate Analyses

An annual income of greater than $60 000 and cost per advertisement
were not found to be significant independent predictors or confounders of
other parameter estimates and were therefore dropped from the final model.

We tested the robustness of our model. Sports Illustrated, with both a high number of adolescent readers and the highest number
of alcohol advertisements, might have had a disproportionate influence on
the regressions. Removing the magazine from the sample did not change the
associations. In addition, to account for the possibility that the relationship
between advertisements and readership might not be log linear, we added a
quadratic term for readership among those aged 12 to 19 years. The quadratic
component was not a significant contributor in any of the analyses, suggesting
a mostly log-linear association between alcohol advertisements and readership
among those aged 12 to 19 years.

COMMENT

To our knowledge, this study is the first to use advertisement placement
frequency to statistically examine the association between alcohol industry
magazine advertising and adolescent readership. We found that after adjustment
for age, sex, race, and household income of magazine readers, as well as year,
frequency of publication, and cost per advertisement, both beer and distilled
liquor advertisements appeared more frequently in magazines with higher adolescent
readership from 1997 through 2001. This relationship was nearly log linear,
with the frequency of advertising increasing exponentially as adolescent readership
increased. We did not find the same relationship for wine and wine cooler
advertisements. Young adult readership was associated with distilled liquor
and wine and wine cooler advertisements, but not beer advertisements.

A number of our findings are consistent with the demographics of alcohol
consumption.35 Men tend to consume beer, blacks
tend to consume distilled liquors, and individuals who earn a high income
tend to consume distilled liquors and wine. Beer, distilled liquor, and wine
coolers are all consumed more by young adults than older adults. Older adults
tend to prefer wine to other types of alcohol. As one would expect, the adult
groups most likely to drink a particular product were essentially the same
adult groups whose readerships correlated most with that product's advertisements.
Given this context, it is concerning that the types of alcohol preferred by
adolescents (beer and distilled liquor) were also found to be the same types
of alcohol whose advertising was most strongly associated with adolescent
readership.30 While these findings do not establish
causality between advertising and adolescent consumption, they do suggest
that alcohol advertisers may be aware of adolescent consumption demographics.

We are unable to determine if the beer and distilled liquor industries
intentionally target adolescents. The extensive history of tobacco research
supports, however, the existence and importance of unintentional targeting.
Citing expert opinion in a trial involving tobacco advertising, the Superior
Court of California defined the 2 types of targeting.

The first kind of targeting, direct targeting, occurs where the
advertiser intends to deliberately target members of a particular group. The
second type of targeting, indirect targeting, occurs when there is no demonstrable
evidence of intent to target, but nevertheless a group other than the group
directly targeted is reached in a measurable way similar to the group directly
targeted.40

At a minimum, our results suggest that both the beer and distilled liquor
industries indirectly targeted adolescent readers, as defined by the courts.40 Even in the absence of direct targeting, any practices
through which adolescent exposure to advertising exceeds expected incidental
levels are an important public health concern, given the prevalence of adolescent
drinking, its negative health effects, and the likely association between
alcohol advertising and consumption. Our study also suggests that such practices
can be avoided. The wine industry appears to be able to focus advertising
on their intended targets (higher-income adults, including young adults) without
increasing adolescent exposure.

Our study has limitations. First, our sample of 35 magazines may not
be representative of all magazines. Nevertheless, these magazines are among
the most widely read in the United States and account for $700 million of
alcohol advertising expenditures, approximately half of all magazine advertisement
expenditures by the alcohol industry during the study period.30- 33 Second,
magazine advertisements may not be representative of all advertising. Magazines
attract a minority of alcohol advertising expenditures, particularly with
respect to beer, and are skewed toward distilled liquor advertisements, which
face higher barriers to entry on television. Nevertheless, magazines still
account for a quarter of the total expenditures and the large majority of
distilled liquor expenditures.31- 33,41 Even
if magazine advertisements prove not to be representative of all advertising,
they are still important in their own right. Third, not all advertisements
are created equal. Our advertisement counts did not distinguish, for instance,
between the effects of an advertisement occupying 1 advertisement space out
of 20 and an advertisement occupying 1 advertisement space out of 200. Nor
did we evaluate the content of any of these advertisements. Finally, it is
possible that we did not account for important confounders. However, we did
account for many of the most important known or suspected magazine-level factors,
and even these covariates produced little change from the initial bivariate
results for beer and distilled liquor advertisements. Regardless of the presence
of unmeasured factors, our findings make clear that a large number of adolescent
readers are routinely exposed to beer and liquor advertisements in magazines.

We conclude that self-regulation by the alcohol industry is not adequately
preventing indirect targeting of adolescents through magazines. In the tobacco
industry, similar self-regulation in the 1990s failed, even in the context
of intense public scrutiny and civil agreements.39 Mechanisms
to monitor and enforce compliance with alcohol industry codes may bring the
industry to a zero-tolerance stance on indirect adolescent targeting. If self-regulation
remains ineffective, a third party, such as the government or an independent
private auditor, may need to be empowered with the ability and authority to
help monitor media advertising. In addition, the advertising agencies that
create the advertisements and the magazines that publish them should recognize
that alcohol could not be marketed to adolescents without their active involvement.
Cooperation among the alcohol, advertising, and magazine industries may be
one way to eliminate indirect adolescent targeting. As written in the Beer
Institute Advertising and Marketing Code, all parties should be "responsible
corporate citizens, sensitive to the problems of the society in which they
exist, and their advertising should reflect that fact."27

REFERENCES

US Department of Health and Human Services. Healthy People 2010: With Understanding and Improving
Health and Objectives for Improving Health.2nd ed. Washington, DC: US Government Printing Office; 2000.

Traffic Safety Facts 1997: A Compilation of Motor Vehicle Crash
Data From the Fatality Analysis Reporting System and the General Estimates
System . Washington, DC: National Highway Traffic Safety Administration; 1998.

Wechsler H, Dowdall GW, Maenner G, Gledhill-Hoyt J, Lee H. Changes in binge drinking and related problems among American college
students between 1993 and 1997: results of the Harvard School of Public Health
College Alcohol Study. J Am Coll Health.1998;47:57-68.

Grube JW. Television alcohol portrayals, alcohol advertising, and alcohol expectancies
among children and adolescents. In: Martin SE, ed. Effects of the Mass Media on
Use and Abuse of Alcohol. Bethesda, Md: National Institute on Alcohol
Abuse and Alcoholism; 1995:105-121.

References

US Department of Health and Human Services. Healthy People 2010: With Understanding and Improving
Health and Objectives for Improving Health.2nd ed. Washington, DC: US Government Printing Office; 2000.

Traffic Safety Facts 1997: A Compilation of Motor Vehicle Crash
Data From the Fatality Analysis Reporting System and the General Estimates
System . Washington, DC: National Highway Traffic Safety Administration; 1998.

Wechsler H, Dowdall GW, Maenner G, Gledhill-Hoyt J, Lee H. Changes in binge drinking and related problems among American college
students between 1993 and 1997: results of the Harvard School of Public Health
College Alcohol Study. J Am Coll Health.1998;47:57-68.

Grube JW. Television alcohol portrayals, alcohol advertising, and alcohol expectancies
among children and adolescents. In: Martin SE, ed. Effects of the Mass Media on
Use and Abuse of Alcohol. Bethesda, Md: National Institute on Alcohol
Abuse and Alcoholism; 1995:105-121.

Letters

The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.
The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with
the extent of their participation in the activity. Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.

This feature is provided as a courtesy. By using it you agree that that you are requesting the material solely for personal, non-commercial use, and that it is subject to the AMA's Terms of Use. The information provided in order to email this article will not be shared, sold, traded, exchanged, or rented. Please refer to The JAMA Network's Privacy Policy for additional information.

Athens and Shibboleth are access management services that provide single sign-on to protected resources. They replace the multiple user names and passwords necessary to access subscription-based content with a single user name and password that can be entered once per session. It operates independently of a user's location or IP address. If your institution uses Athens or Shibboleth authentication, please contact your site administrator to receive your user name and password.

What is this ?

Article rental gives users the ability to access the full text of an article and its supplementary content for 24 hours.
Access to the PDF is only available via article purchase.